Provider Demographics
NPI:1295714491
Name:FULLER, VIRGINIA S (MD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:S
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65457
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0457
Mailing Address - Country:US
Mailing Address - Phone:706-860-2701
Mailing Address - Fax:
Practice Address - Street 1:1010 COLLEGE ST
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2507
Practice Address - Country:US
Practice Address - Phone:919-690-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200101045207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89135YAMedicaid
B35391Medicare UPIN
NC2021574AMedicare PIN